Ретробульбарная анестезия (РА)

Если правильно помню - то глаз после прохождения иглой мышечной воронки совершит легкое движение книзу.. что и будет косвенным контролем (одним из немногих..) попадания в ретробульбарное пространство...
При определеных случаях лучше подходит субтеноновая анестезия, или перибульбарная проводимая под зрительным контролем со стороны конъюнктивы века...Принципы те же.
Пожалуй лучшие описания в книге "Ошибки микрохирургии в офтальм." - Джалиашвили, Горбань. (ярко-синяя обложка)
переводной вариант книги по факоэмульсификации Буратто...
оригиналы на английском... Если будет интересно сбросьте почту перешлю...

цель ретробульбарной анестезии - достичь анестезии путём воздействия на цилиарное тело. А оно располагается, насколько я помню, в нескольких миллиметрах от заднего полюса глазного яблкока вблизи зрительного нерва, кнаружи от него. Поэтому глаз должен отклоняться (по логике) в противоположную от укола сторону, а вкол должен производиться, соответсвенно, ближе к височной части орбиты

Цилиарный узел, простите.

да - узел, ганглион. но гость это не я, по спешке - решил, что описался..
Цитата из Glaucoma Surgery edidet by Graham E.Trope 2005год.
4.4. Retrobulbar Anesthesia
4.4.1. Technique
* For retrobulbar anesthesia, light general sedation and analgesia should be started before the retrobulbar is started. It is important that the patient remains cooperative during the retrobulbar. After the retrobulbar, more sedation can be supplied.
* A 1:1 mixture of lidocaine (2%, 1.5 mL) without epinephrine and bupivacaine (0.5%, 1.5 mL) should be used, with or without hyaluronidase (5 U/mL). There is poor evidence that adding hyaluronidase increases the effectiveness of these blocks at producing akinesia (26). We do not use hyaluronidase in our unit.
* A maximum of 3 mL retrobulbar injection is administered with the globe in primary position preferably via a short blunt 25–27-gauge (31 mm) needle on a 5–10 mL syringe. This provides consistent tactile feedback for both insertion of the needle and injection of the anesthetic, which in turn, provides reliable and safe blocks. Several techniques for the administration of retrobulbar block have been described, however, no single method has established a striking advantage in safety or efficacy. We recommend an entry site through the lower lid at the junction of the lateral and middle third of the inferior orbital rim with the eye in the primary position with the needle initially directed parallel to the floor of the orbit aimed at the opposite mandibulary process.
* It is very important to feel the lower border of the globe through the lid prior to needle insertion. The globe size is determined and only then the needle inserted 1–2 mm below the lowest edge of the globe. Once passed the equator the needle can be tilted 208 with the tip towards superior orbit to facilitate entry to the muscle cone. A slight “give” from the inferior rectus can sometimes be felt. The hub of the needle should not go beyond the inferior orbital rim. Any pain reported by the patient may signal contact with the sclera and should prompt partial withdrawal and redirection of the needle.
* After aspiration to rule out intravascular placement, 1–3 mL of anesthetic solution is injected slowly (1 mL/10 s) (27). It is important not to deliver a large bolus into the muscle cone, as the increased pressure around an atrophic glaucomatous nerve can damage it. There should be little resistance to injection.
* Fullness and mild ptosis of the upper lid will be evident towards the end of the injection. The tension in the orbit should be monitored manually. On no account should pressure be applied to the glaucomatous eye to disperse the anesthetic. Pressure from a Honan’s balloon with orbital pressure from the injection bolus can cause dangerous reduction in optic nerve head perfusion possibly leading to “wipe out” of remaining field.
* On withdrawal, orbicularis akinesia is achieved with injection of 1.5 mL of the same anesthetic solution slowly (1 mL/s) anterior to the septum orbitale. Supplementary injections may be needed in
10% of cases. It takes around 10 min for most retrobulbar injections to exert their maximal effect.
Evaluation of the block involves: - Paralysis in all positions of gaze and ptosis help you to decide whether there is adequate anesthesia.
If there is excessive movement or if more than two muscles are still active at 10 min, a further 1.0 mL of the anesthetic mixture should be given in the same manner. Some activity of the superior oblique persists after the recti are completely blocked, probably from incomplete spread of the anesthetic to the superonasal/posterior aspect of the orbit where cranial nerve IV supplies the superior oblique (28).
Дальше идут осложнения, методика имеет свои преимущества и недостатки. Взято с http://opthalmology.blogspot.com/search/label/Glaucoma
Есть в монографии Краснова по анатомии - стр. 93